The writing was on the wall, and Neil Halpern, MD, FCCM, director of the intensive care unit (ICU) at Memorial Sloan-Kettering Cancer Center (MSKCC), could see it. Soon, due to nationwide resident staffing shortages, house staff duty-hour restrictions, and an increasing population of elderly, critically-ill patients, it would be difficult to staff his new and expanding ICU appropriately.
His response? Bring in different providers: specifically, nurse practitioners and physician assistants.
Creating a Critical Care NP and PA Team
“During the planning stages for our ICU expansion from 12 to 20 beds, it was apparent that additional house staff was not available or necessarily wanted,” says Halpern. “We explored the option of enlarging our critical care team with NPs and PAs. Five years later, the ICU NP-PA team has far exceeded all of our expectations and has raised the bar at Memorial for superb delivery of patient care and multidisciplinary practice.”
MSKCC launched its ICU nurse practitioner training program in the spring of 2007, originally with six providers. It has now grown to 25 providers, with the recent addition of a PA. Overall, the program has been so successful that the critical care medicine service has taken on the added responsibilities of managing the hospital’s rapid response team, training NPs for other MSKCC medical and surgical services, and building a robust preceptorship program in conjunction with local nursing schools NP programs, including those at New York University and the University of Pennsylvania.
Teamwork for Seamless Care
Teamwork in MSKCC’s ICU occurs on multiple levels: between the NPs and PAs themselves, between day and night NP and PA shifts, among NPs, PAs and the attending physicians, and among NPs, PAs, nurses, respiratory therapists and ancillary staff.
“Really coordinated teamwork is crucial to getting things done quickly and efficiently,” says Camille Lineberry, ACNP-BC, CCRN, a critical care nurse practitioner at MSKCC. “We see this in action when a patient comes to us in extremis: one NP is inserting catheters, one is ordering admission labs and tests, one is on the phone with consult services and family members – sometimes it’s so seamless, it’s like being in the zone,” Lineberry adds.
Faced with complex critical illnesses, and expected to practice with considerable autonomy, the NPs and PAs very much rely on a joint effort to maintain excellent patient care delivery. MSKCC’s critical care NP and PA practitioners are responsible for 10 to 14 beds in a 20-bed medical-surgical adult ICU. The group, under the supervision of ICU attending physicians, rounds daily, performs invasive procedures, orders and interprets diagnostic tests, coordinates complex care with other medical services, documents daily progress notes, and collects research data on the patients in their care. Additionally, the NPs and PAs answer RRT calls and perform critical care medicine consultations on demand.
|From left to right: Kate Tayban, ACNP-BC, Yulia Kit, PA-C, Rhonda D’Agostino, ACNP, Neil Halpern, MD, FCCM, Christine Freise ACNP-BC, Tara Buchholz, ACNP-BC.|
“As primary responders for the hospital’s rapid response team, the NPs and PAs play a significant role collaborating on sick patients that need escalation of care. Without teamwork and expertise, our rapid response team program would not be as successful as it is today,” says Rhonda D’Agostino, ACNP-BC, CCRN, CEN, ICU NP coordinator.
Training Programs and Sharing Best Practices
If teamwork is important to the MSKCC critical care NPs and PAs, education is doubly so. The training program for the ICU NPs and PAs is extensive, and includes 6 weeks of lectures, diagnostic test interpretation (EKGs, chest radiographs, CT and ultrasound imaging), instruction in performing arterial and central line insertion and endotracheal intubation, and training in ultrasound for exams and procedures. The NPs and PAs also go to the operating room to gain experience in airway management and observation of complex surgical procedures.
In fact, the training program has so improved the critical care NPs’ and PAs’ knowledge base, clinical reasoning and diagnostic skills, and overall professional performance, that the critical care medicine service recently decided to offer the local intensivist and NP and PA provider communities an in-depth look at the process of building a critical care medicine NP-PA program.
“We felt the time was ripe to share our experiences – both our struggles and triumphs – in order to help out other ICUs that are just beginning the process of adding NPs and PAs,” says Kate Tayban, ACNP-BC, GNP, OCN, critical care NP at MSKCC. Tayban adds that nurse practitioners and physician assistants are so new in intensive care units that hospitals end up reinventing the wheel when adding these providers to their ranks.
Accordingly, in December, 2011, the MSKCC critical care medicine service held the first critical care symposium in the New York tri-state area dealing exclusively with NP and PA training and practice, with over 150 in attendance. Presentations focused on training NP and PA critical care teams, using NPs and PAs to run the rapid response team, and reporting on ICU RN satisfaction with NP and PA performance. Additionally, basic lectures ranging from ventilator management, updates in sepsis and using ultrasound in critical care were well received. A tour of the MSKCC ICU, which received the 2009 ICU Design Citation award from the Society of Critical Care Medicine, the American Association of Critical Care Nurses and American Institute of Architects Academy on Architecture for Health, was also provided.
“The critical care NP-PA symposium was quite a success due to the teamwork and support of our dedicated ICU group,” says Jibran Majeed, ACNP-BC, CCRN, critical care NP at MSKCC.
The MSKCC critical care medicine service plans to offer the course annually, given the success of the first program and the expected increases in demand for ICU coverage in the coming years.
Cami Lineberry, ACNP-BC, has been an intensive care unit NP at Memorial Sloan-Kettering Cancer Center for 4 years.